Provider Demographics
NPI:1902962905
Name:CENTRAL CONNECTICUT RADIATION ONCOLOGY PC
Entity Type:Organization
Organization Name:CENTRAL CONNECTICUT RADIATION ONCOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:NEAL
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-224-5520
Mailing Address - Street 1:760 SAYBROOK RD BLDG A
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4785
Mailing Address - Country:US
Mailing Address - Phone:860-704-0106
Mailing Address - Fax:860-704-0125
Practice Address - Street 1:536 SAYBROOK RD
Practice Address - Street 2:MIDDLESEX HOSPITAL CANCER CENTER
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-704-0106
Practice Address - Fax:860-704-0125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCCRO4074712Medicaid
CTCCRO4074712Medicaid
C00786Medicare PIN
E01278Medicare UPIN
D85330Medicare UPIN
E01279Medicare UPIN
CTCCRO4074712Medicaid